Name *

First Name

Last Name

Phone *

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Outreach Details *

We will be driving to and from SWFL (19 hr drive). We will be participating in debriefing training (CEs will be given), assembling & distributing gift bags. We will be offering peer support and debriefing with SWFL nurses. There may be an opportunity for community clean up. Your travel, stay and meals will be covered. We are asking for $50-$100 to contribute to funds.

I agree to all above

I do not agree with portions of above